Friday 19 April 2019

Patients with delirium finally getting attention they deserve

It's amazing how rarely this common condition is discussed, write Colm Cunningham and Shaun O'Keeffe

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When older people, and particularly those who are physically frail or have a dementia such as Alzheimer's disease, become ill, they often develop a quite sudden onset of confusion where they may not know where they are, are agitated or drowsy, have difficulty concentrating and are frightened and distressed. Some people get visual hallucinations or develop troubling delusions (false beliefs). Symptoms fluctuate and are often worse at night. This condition is known as delirium and it is extremely common.

A few years ago, a crack squad of Irish geriatricians and psychiatrists entered Cork University Hospital at dawn and by nightfall they had assessed practically every person in the hospital for delirium. They found that about one in five people overall, and more than a third of those over 80 years old, in a typical Irish general hospital and on a typical day, had delirium. As well as being common, delirium is significant because people who become delirious often have a more prolonged and troubled stay in hospital than those without delirium. It is harder, for example, to maintain adequate intake of food and fluid and they may become incontinent and lose mobility.

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What's amazing, given how common it is, is how rarely delirium is discussed in public life, and yet, when talking about our research with others, people always seem to have their own delirium story: of a parent, a husband or wife, a grandparent who had a bad time at the hospital, perhaps during an infection: "They weren't themselves", "He didn't know where he was", "She was convinced the nurses were trying to hurt her". These episodes are bewildering and troubling to patients and carers, but delirium is poorly understood and little discussed with patients or their carers. How come?

One reason is that delirium is often not recognised in the hospital. It is hard to miss that there is something wrong when people become agitated, distressed and uncooperative. However, many people with delirium actually become quiet and withdrawn, and this is harder for staff to spot. Families have an important role here, in these cases particularly, by flagging to staff if they notice a change in their loved ones' mental condition and thinking.

Delirium is complex. Just about any condition or medication can trigger it. Among the most important culprits are medications, especially those that affect the brain, such as strong painkillers, and infections. It is also very common in those who have a hip fracture and need surgery. There is often more than one cause. For example, those who develop a severe infection will also often become dehydrated and these factors may combine to produce a bigger problem than either factor alone. Family members often worry that someone with delirium has had a stroke. However, unless there are other signs that stroke has developed, such as weakness in the limbs, this is uncommon, and most people with delirium don't need (and might even be distressed by) brain scanning.

Delirium is not the same as dementia. In particular, delirium is a new and sometimes dramatic onset of disturbed brain function, while most dementias develop slowly and insidiously. There is a complex relationship between the two problems, though. People with dementia are much more likely to become delirious while ill and this can occur with a relatively mild illness or even as a result of changes in their medications. In contrast, it often takes a very serious illness, such as one needing intensive care, to make a younger person delirious. In some cases, problems with memory and other brain functions have developed so gradually that they haven't been noticed until a new illness, and an episode of delirium, leads to the recognition that the person has an underlying dementia.

What can be done about delirium? The first thing is to identify and treat whatever illness caused it. While waiting for this to benefit the patient, it is important to support the person by maintaining nutrition, hydration and mobility. Although stopping medications can often improve delirium, unfortunately, at least with our current understanding of delirium, giving medications can't fix it. Giving medication, such as antipsychotics to calm the person - in as low a dose as possible for as short a period as possible - may be unavoidable if someone is very agitated or distressed but these drugs don't really reverse delirium and side effects can also occur.

Some of the most important things we can do to benefit the person with delirium are also the simplest - in theory. If people are disoriented and frightened, they need kindness, frequent reassurance and explanation as to what is happening.

Having familiar objects and familiar people around them is often helpful. People with delirium need peace and calm to help their recovery. Alas, the Irish health service at present may be unable to provide this despite the best efforts of staff.

The good news is that delirium is transient and reversible in the great majority of people. The bad news is that, while recovery often occurs within days in fitter, younger people, it sometimes takes weeks in older, frailer people or in those who suffered particularly severe illness. It is also common that people who have recovered from delirium 'half-remember' their experiences, are bothered by them and are afraid they will recur. 'Debriefing' to explain what has happened often helps and many hospitals keep patient diaries so patients can be helped to distinguish between the distressing experiences they had while in their altered mental state and the events that actually occurred in the real world of the hospital ward.

Basic neuroscience research is also beginning to explain why and how delirium develops and this may lead to new focused approaches to prevention and treatment. There are reasons for optimism here, but neuroscience research requires sustained funding if we are tackle the complex challenges of delirium and dementia.

Delirium is a very common, distressing and medically important phenomenon. Long ignored by clinicians and researchers, patients with delirium are finally beginning to get the attention they need and deserve.

The authors of this piece will contribute to a public event entitled 'Delirium! When acute illness meets dementia' this Tuesday at 7pm in the Tercentenary Hall, Trinity Biomedical Sciences Institute, 152-160 Pearse Street (Trinity College Dublin). Tea/coffee from 6pm in TBSI. The event is free but registration is recommended at www.eventbrite.com/e/delirium-when-acute-illness-meets-dementia-tickets-58979121139.

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